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Employee's Full Name
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Re: Designation Notice - FMLA/NJFLA
Dear Employee Name,
Attached is the Designation Notice with regard to your application for leave under FMLA/
NJFLA. Please review the notice and contact me if you have any questions.
Should your health care provider return you to work with restrictions, please contact your
campus Human Resources Representative referenced below, and submit the completed
Accommodation Request Form and the Accommodation Request: Medical Inquiry Form in
order to request reasonable accommodations.
It is recommended that you contact your Human Resources Representative at least (2) two
weeks prior to your anticipated return to work date, should you have any work restrictions.
The guidelines for Disability Accommodations, the Accommodation Request Form, and the
Accommodation Request: Medical Inquiry Form can be found at:
http://uhr.rutgers.edu/ee/DisabilityAccomm.htm.
Sincerely,
Name
Title of Sending Authority
Human Resources Representatives:
▪ New Brunswick Campus: Laxmi Vazirani, Disabilities Specialist - (848) 932-3974
▪ Newark Campus: Judith Crespo, Senior Benefits Specialist - (973) 353-5234
▪ Camden Campus: Greg O'Shea, Human Resources Manager - (856) 225-6475
Designation Notice
(Family and Medical Leave Act & New Jersey Family Leave Act)
Leave covered under the Family and Medical Leave Act (FMLA) must be designated as FMLA-protected and the
employer must inform the employee of the amount of leave that will be counted against the employee's FMLA leave
entitlement. In order to determine whether leave is covered under the FMLA, the employer may request that the
leave be supported by a certification. If the certification is incomplete or insufficient, the employer must state in
writing what additional information is necessary to make the certification complete and sufficient. This form, when
fully completed, provides an easy method of providing employees with the written information required by federal
and state law. Please refer to University policy 60.3.8 - Family Leave.
From:
Date:
To:
We have reviewed your request for leave under the FMLA and the NJFLA and any supporting documentation
[Enter Date]
that you have provided. We received your most recent information on
and decided:
Your
All leave taken for this reason will be designated as FMLA
and/or NJFLA leave as outlined below:
Your applicable sick time exhausts on
Your FMLA begins on
and ends on
Your NJFLA begins on
Continuous leave
and ends on
Intermittment leave
Reduced leave
(Enter schedule above)
The FMLA/NJFLA require that you notify us as soon as practicable if dates of scheduled leave change or
are extended, or were initially unknown. Based on the information you have provided to dates, we are
providing the following information about the amount of time that will be counted against your leave
entitlement:
Provided there is no deviation from your anticipated leave schedule, the following number of hours,
days or weeks that will be counted against your leave entitlement:
Because the leave you will need will be unscheduled, it is not possible to provide the hours, days, or
weeks that will be counted against your FMLA and/or NJFLA entitlement at this time. You have the
right to request this information once in a 30-day period (if leave was taken in the 30-day period).
Please be advised (check if applicable):
You have requested to use
Vacation
AL
PH days during your unpaid
(Enter number of days)
Any paid leave taken for this reason will count against your FMLA and/or
NJFLA leave entitlement as checked.
You will be required to present a fitness-for-duty certificate to be restored to employment. If such
certification is not timely received, your return to work may be delayed until certification is provided.
A list of essential functions of your position
is
is not attached. If attached, the fitness-for-duty
certification must address your ability to perform these essential functions.
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University Human Resources
57 U.S. Highway 1 · New Brunswick, NJ 08901-8554
(848) 932-3020 · FAX (732) 932-0046 · uhr.rutgers.edu
Aug 2011
Additional information is needed to determine if your FMLA and/or NJFLA leave
request can be approved:
The certification you have proved is not complete and sufficient to determine whether the
FMLA/NJFLA applies to your leave request. You must provide the following information no
later than
, unless it is not practicable under the particular
(Provide at least seven calendar days)
circumstances despite your diligent good faith efforts, or your leave may be denied.
(Specify information needed to make the certification complete and sufficient)
We are exercising our right to have you obtain a second or third opinion medical certification at
our expense, and we will provide further details at a later time.
Your
The
leave request is Not Approved.
does not apply to your leave request.
You have exhausted your FMLA leave entitlement in the applicable 12-month period.
You have exhausted your NJFLA leave entitlement in the applicable 24-month period.
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
It is mandatory for employers to inform employees in writing whether leave requested under the FMLA has been determined
to be covered under the FMLA. 29 U.S.C. § 2617; 29 C.F.R. §§ 825.300(d), (e). It is mandatory for employers to retain a copy of
this disclosure in their records for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500. Persons are not required to respond to this
collection of information unless it displays a currently valid OMB control number. the Department of Labor estimates that it
will take an average of 10 -30 minutes for respondents to complete this collection of information, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this
collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour
Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210. DO NOT SEND THE
COMPLETED FORM TO THE WAGE AND HOUR DIVISION.
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Aug 2011
University Human Resources
57 U.S. Highway 1 · New Brunswick, NJ 08901-8554
(848) 932-3020 · FAX (732) 932-0046 · uhr.rutgers.edu